John W. Hafner

Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management.

OBJECTIVES The aims of this study were to 1) estimate differences in pain management process and patient-reported outcomes, pre- and postimplementation of analgesic protocols for adults with sickle cell disease (SCD), and 2) examine the effects of site and visit frequency on changes in pain scores and time to analgesic. METHODS A multicenter, prospective, longitudinal study enrolled patients from three academic medical centers between October 2007 and September 2009. All ED patients 18 years or older with a chief complaint of a sickle cell pain episode were enrolled. Sites formed a SCD quality improvement (QI) team and implemented standard nurse-initiated emergency department (ED) analgesic protocols; outcomes were compared between study periods defined as pre- and postimplementation of protocols. Medical record review was conducted to measure time to administration of initial analgesic, opioids used, route of opioid administration, the change in pain scores from arrival to discharge (negative numbers reflect a decrease in pain scores), and the number of ED visits per individual patient during the study period at each site. On day 7 after the ED visit, a follow-up phone interview was conducted. Patients were queried about their ED pain management using a scale from 1 to 10 (1 = outstanding, 10 = worst). Descriptive statistics are used to report the results. Ordinary least-squares regression models were constructed to measure the effect of time period, site, and number of visits per patient on change in pain score. RESULTS During the study period, 342 unique patients (57% female, mean ± SD age = 32 ± 11 years) were enrolled and had a total of 2,934 visits. There was no difference in time to administration of the initial analgesic between study periods. Overall, there was a significant decrease in pain scores from arrival to discharge between the pre- and postintervention study periods: the average difference in arrival to discharge pain scores (cm) was greater during the postimplementation period than during the preintervention period (-4.1 vs. -3.6, t = 2.6, p < 0.01). Site 1 had significant improvement between study periods (mean difference = -0.87, t = 2.63, p < 0.01; F = 14.3, p < 0.01). Patients with few ED visits (one to six annual visits, mean difference = -1.55, t = 2.1, p = 0.04) and those with frequent ED visits (7 to 19 annual visits, mean difference = -1.65, t = 3.52, p < 0.01) had a significant decrease in pain scores compared to patients with very frequent ED visits (>19 visits). There was an overall decrease in the use of morphine sulfate (MS) and increase in the use of hydromorphone (χ(2) = 105.67, p < 0.001) between study periods and a significant increase in the use of oral (PO) and subcutaneous (SC) routes, with a corresponding decrease in the intravenous (IV) route (χ(2) = 13.67, p < 0.001). There were no statistically significant differences in patient-reported satisfaction with the attempt to manage pain in the ED between study periods (p = 0.54). CONCLUSIONS While the use of a learning collaborative and implementation of nurse-initiated analgesic protocols was not associated with improvement in time to administration of the initial analgesic, improvements in the decrease in the arrival to discharge pain score and increased use of hydromorphone and the SC route were noted in adults with SCD in the ED.

Adult Emergency Department Patients with Sickle Cell Pain Crisis: A Learning Collaborative Model to Improve Analgesic Management

OBJECTIVES The objectives were to report the baseline (prior to quality improvement interventions) patient and visit characteristics and analgesic management practices for each site participating in an emergency department (ED) sickle cell learning collaborative. METHODS A prospective, multisite longitudinal cohort study in the context of a learning-collaborative model was performed in three midwestern EDs. Each site formed a multidisciplinary team charged with improving analgesic management for patients with sickle cell disease (SCD). Each team developed a nurse-initiated analgesic protocol for SCD patients (implemented after a baseline data collection period of 3.5 months at one site and 10 months at the other two sites). All sites prospectively enrolled adults with an acute pain crisis and SCD. All medical records for patients meeting study criteria were reviewed. Demographic, health services, and analgesic management data were abstracted, including ED visit frequency data, ED disposition, arrival and discharge pain score, and name and route of initial analgesic administered. Ten interviews per quarter per site were conducted with patients within 14 days of their ED discharge, and subjects were queried about the highest level of pain acceptable at discharge. The primary outcome variable was the time to initial analgesic administration. Variable data were described as means and standard deviations (SDs) or medians and interquartile ranges (IQR) for nonnormal data. RESULTS A total of 155 patients met study criteria (median age = 32 years, IQR = 24-40 years) with a total of 701 ED visits. Eighty-six interviews were conducted. Most patients (71.6%) had between one and three visits to the ED during the study period. However, after removing Site 3 from the analysis because of the short data enrollment period (3.5 months), which influenced the mean number of visits for the entire cohort, 52% of patients had between one and three ED visits over 10 months, 21% had four to nine visits, and 27% had between 10 and 67 visits. Fifty-nine percent of patients were discharged home. The median time to initial analgesic for the cohort was 74 minutes (IQR = 48-135 minutes). Differences between choice of analgesic agent and route selected were evident between sites. For the cohort, 680 initial analgesic doses were given (morphine sulfate, 42%; hydromorphone, 46%; meperidine, 4%; morphine sulfate and ibuprofen or ketorolac, 7%) using the following routes: oral (2%), intravenous (67%), subcutaneous (3%), and intramuscular (28%). Patients reported a significantly lower targeted discharge pain score (mean +/- SD = 4.19 +/- 1.18) compared to the actual documented discharge pain score within 45 minutes of discharge (mean +/- SD = 5.77 +/- 2.45; mean difference = 1.58, 95% confidence interval = .723 to 2.44, n = 43). CONCLUSIONS While half of the patients had one to three ED visits during the study period, many patients had more frequent visits. Delays to receiving an initial analgesic were common, and post-ED interviews reveal that sickle cell pain patients are discharged from the ED with higher pain scores than what they perceive as desirable.

Evaluation of a standardized all-terrain vehicle safety education intervention for youth in rural Central Illinois.

Background: Although research investigating all-terrain vehicle (ATV) riders and ATV injury patterns has led to support for legislative and educational efforts to decrease injuries in users younger than 16 years, there is little published data regarding the utility of ATV safety education programs. This study investigates the effectiveness of a standardized adolescent ATV safety program in changing the safety knowledge and safe ATV riding practices reported by rural Central Illinois youths. Methods: A convenience sample of 260 rural Central Illinois middle and high school students received an ATV safety presentation with both didactic and interactive features during the 2009-2010 school year. Preintervention and postintervention surveys were distributed and collected by teachers. Survey questions consisted of multiple-choice questions pertaining to demographics, ATV safety knowledge, and ATV riding practices. More than 200 surveys were collected prior to the intervention and 165 surveys were collected 12 to 24 weeks after the intervention. Percentages are reported, with differences in nominal variables tested by χ2 test and interval variables by t test. Results: Following the intervention, there was a significant increase in the correct response rate for ATV safety knowledge questions (45.2% vs 56.2%, P < .001). For adolescents who reported riding ATVs, both safety gear use (11.8% to 21.2%, P = .05) and helmet use (25.4% to 29.0%, P = .56) increased; changes were not significant. Adolescent ATV riders reporting 2 or more accidents showed a slight nonsignificant decrease (25.2% vs 23.4%, P = .77) between the time of the pretest and posttest. Conclusion: This safety program was effective at increasing ATV safety knowledge but demonstrates limited effect on safe riding practices.

Bilateral internuclear ophthalmoplegia following minor head trauma

Internuclear ophthalmoplegia (INO) is characterized by pathognomonic findings on neurological examination. It results from a lesion in the medial longitudinal fasciculus (MLF) and is rarely caused by head trauma. The neuroanatomy of INO is complex and the mechanism by which trauma causes this syndrome is controversial. In the context of trauma, INO occurs frequently in association with other neurological findings and should prompt a thorough investigation and ICU admission. A case of an individual with acute post-traumatic INO is reported and discussed.

Emergency department pediatric all-terrain vehicle injuries in West Central Illinois.

Objectives: This study was prepared to evaluate pediatric all-terrain vehicle-related injuries treated in a tertiary care emergency department in West Central Illinois. Methods: A retrospective descriptive study was performed of local emergency department cases entered into the US Consumer Product Safety Commission database. All visits involving an all-terrain vehicle-related injury in children younger than 18 years from January 1994 to December 2001 were explicitly reviewed and compared with aggregate national Consumer Product Safety Commission pediatric all-terrain vehicle data. Results: One hundred eighty-seven children (age range, 2-17 years) from 14 West Central Illinois counties were treated in the emergency department during the study period. Injury patterns followed a national trend of an increasing annual incidence after 1998 (P = 0.05). The majority of patients were boys (78%) and were 12 years or younger (71%). Contusions (31.8%), fractures (25%), and lacerations (18.8%) accounted for the majority of injuries. Although observed injuries correlated well with national injury estimates for injury position, age, and sex, more head and chest injuries were noted locally. Derived injury severity scores had a mean of 3.1 (range, 1-50), and no difference was noted in the injury severity score for helmet use, sex, or age younger than 12 years. Conclusions: Overall, the incidence of all-terrain vehicle-related injuries in West Central Illinois in the emergency department is increasing, and local injury patterns correlate well with those reported on a national level.

Diagnostic utility of the genital Gram stain in ED patients

OBJECTIVE The study aimed to determine the diagnostic usefulness of the genital Gram stain in an emergency department (ED) population. METHODS A linked-query of an urban, tertiary-care, university- affiliated hospital laboratory database was conducted for all completed Chlamydia trachomatis and Neisseria gonorrhoeae DNA probes, Trichomonas vaginalis wet preps, and genital Gram stains performed on ED patient visits between January and December 2004. Positive criteria for a Gram stain included greater than 10 white blood cells per high-power field, gram-negative intracellular/extracellular diplococci (suggesting N gonorrhoeae), clue cells (suggesting T vaginalis), or direct visualization of T vaginalis organisms. DNA probes were used as the gold standard definition for N gonorrhoeae and C trachomatis infection. RESULTS Of 1511 initially eligible ED visits, 941 were analyzed (genital Gram stain and DNA probe results both present), with a prevalence of either C trachomatis or N gonorrhoeae of 11.4%. A positive genital Gram stain was 75.7% sensitive and 43.3% specific in diagnosing either C trachomatis and/or N gonorrhoeae infection, and 80.4% sensitive and 32.2% specific when the positive cutoff was lowered to more than 5 white blood cells/high-power field. No Gram stains were positive for T vaginalis (with 47 positive wet mounts), and clue cells were noted on 117 Gram stains (11.6%). CONCLUSION Gram stains in isolation lack sufficient diagnostic ability to detect either C trachomatis or N gonorrhoeae infection in the ED.

Posttraumatic internal jugular vein thrombosis presenting as a painful neck mass in a child.

An uncommon case of a pediatric traumatic internal jugular vein thrombosis is presented. A 7-year-old boy developed severe neck pain after falling from a bunk bed. Initially, the child was diagnosed and treated for a lymphadenitis with a possible abscess formation. Contrast-enhanced computed tomography and Doppler ultrasound imaging of the neck revealed the presence of an occlusive thrombosis of the left internal jugular vein. The patient was treated with intravenous antibiotics and followed closely over the next year. He had full resolution of his symptoms without the development of complications associated with this injury process. Internal jugular vein thrombosis is an uncommon and potentially life-threatening disorder caused by various conditions. This case illustrates the need for a systematic approach when evaluating neck masses, and internal jugular venous thrombosis should be included in the differential of anterior neck swelling.

Symptomatology of HIV-Related Illness and Community-Acquired Illness in an HIV-Infected Emergency Department Population

STUDY HYPOTHESIS Community-acquired infections and non-AIDS-related illnesses are a significant proportion of the final diagnoses in HIV-infected patients presenting to an emergency department. We hypothesized that emergency physicians over-diagnose opportunistic infections in the HIV-infected patient. We also hypothesized that the absolute CD4 lymphocyte level could be used to stratify patients by likelihood of HIV related disease. METHODS We retrospectively reviewed ED logbooks and medical records to find all ED patients with self-reported HIV seropositivity during a 19-month period. Age, sex, insurance status, chief complaint(s), ED assessment, and disposition were recorded from the ED logs; absolute CD4 lymphocyte counts, risk factors, and final diagnoses were recorded from the medical records. HIV-related disease was evaluated with the use of established Centers for Disease Control and Prevention criteria. Data were evaluated with the use of the chi 2 test, the chi 2 test for trend, and kappa-proportions. RESULTS Analysis of 344 ED visits demonstrated that decreasing absolute CD4 lymphocyte counts were associated with increasing incidence of HIV-related disease (P < .001), even when noninfectious causes were excluded. Only 34% of visits were related to HIV-associated illness. Emergency physicians exhibited high sensitivity (72.9%) and specificity (95.5%) in diagnosing HIV-related disease and conducted appropriate visit disposition. CONCLUSION ED visits by HIV-infected individuals are often not made for reasons of opportunistic infection, and the absolute CD4 lymphocyte count is inversely related to HIV-related disease.

Effectiveness of a Drill-assisted Intraosseous Catheter versus Manual Intraosseous Catheter by Resident Physicians in a Swine Model

Introduction: Our objective was to compare the effectiveness, speed, and complication rate of the traditional manually placed intraosseous (IO) catheter to a mechanical drill-assisted IO catheter by emergency medicine (EM) resident physicians in a training environment. Methods: Twenty-one EM residents participated in a randomized prospective crossover experiment placing 2 intraosseous needles (Cook® Intraosseous Needle, Cook Medical, Bloomington, IN; and EZ-IO® Infusion System, Vidacare, San Antonio, TX). IO needles were placed in anesthetized mixed breed swine (mass range: 25 kg to 27.2 kg). The order of IO placement and puncture location (proximal tibia or distal femur) were randomly assigned. IO placement time was recorded from skin puncture until the operator felt they had achieved successful placement. We used 3 verification criteria: aspiration of marrow blood, easy infusion of 10 mL saline mixed with methylene blue, and lack of stained soft tissue extravasation. Successful placement was defined as meeting 2 out of the 3 predetermined criteria. We surveyed participants regarding previous IO experience, device preferences, and comfort levels using multiple choice, Likert scale, and visual analog scale (VAS) questions. IO completion times, VAS, and mean Likert scales were compared using Student’s t-test and success rates were compared using Fisher’s exact test with p<0.05 considered significant. Results: Drill-assisted IO needle placement was faster than manually placed IO needle placement (3.66 versus 33.57 seconds; p=0.01). Success rates were 100% with the drill-assisted IO needle and 76.2% with the manual IO needle (p=0.04). The most common complication of the manual IO insertion was a bent needle (33.3% of attempts). Participants surveyed preferred the drill-assisted IO insertion more than the manual IO insertion (p<0.0001) and felt the drill-assisted IO was easier to place (p<0.0001). Conclusion: In an experimental swine model, drill-assisted IO needle placement was faster and had less failures than manual IO needle placement by inexperienced resident physicians. EM resident physician participants preferred the drill-assisted IO needle.

Promoting use of booster seats in rural areas through community sports programs.

BACKGROUND Booster seats reduce mortality and morbidity for young children in car crashes, but use is low, particularly in rural areas. This study targeted rural communities in 4 states using a community sports-based approach. OBJECTIVE The Strike Out Child Passenger Injury (Strike Out) intervention incorporated education about booster seat use in children ages 4-7 years within instructional baseball programs. We tested the effectiveness of Strike Out in increasing correct restraint use among participating children. METHODS Twenty communities with similar demographics from 4 states participated in a nonrandomized, controlled trial. Surveys of restraint use were conducted before and after baseball season. Intervention communities received tailored education and parents had direct consultation on booster seat use. Control communities received only brochures. RESULTS One thousand fourteen preintervention observation surveys for children ages 4-7 years (Intervention Group [I]: N = 511, Control [C]: N = 503) and 761 postintervention surveys (I: N = 409, C: N = 352) were obtained. For 3 of 4 states, the intervention resulted in increases in recommended child restraint use (Alabama +15.5%, Arkansas +16.1%, Illinois +11.0%). Communities in 1 state (Indiana) did not have a positive response (-9.2%). Overall, unadjusted restraint use increased 10.2% in intervention and 1.7% in control communities (P = .02). After adjustment for each state in the study, booster seat use was increased in intervention communities (Cochran-Mantel-Haenszel odds ratio 1.56, 95% confidence interval [1.16-2.10]). CONCLUSIONS A tailored intervention using baseball programs increased appropriate restraint use among targeted rural children overall and in 3 of 4 states studied. Such interventions hold promise for expansion into other sports and populations.